Travel Risks: Update on Traveler's Diarrhea and Other Common Problems
By J. PAUL SEALE, MD |
December 1, 2002
Dr Seale is associate professor in the department of family medicine at Mercer University School of Medicine, Macon, Ga, and is an attending physician at the Medical Center of Central Georgia (also in Macon). He recently served as a medical missionary physician in Venezuela for the International Mission Board of the Southern Baptist Convention.
ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.
As international travel becomes more economical and commonplace, primary care providers are increasingly called on to help prevent related health problems. Most of these problems can be avoided by taking appropriate measures.
In previous articles (CONSULTANT, August 2001, page 1289, and September 1, 2001, page 1431), I focused on travel-specific immunizations and malaria prophylaxis, respectively. Here I discuss protection against traveler's diarrhea, motion sickness, jet lag, altitude sickness, heat- and sun-related conditions, accidents, and sexually transmitted diseases (STDs). I also address the specific hazards of travel for patients with chronic health conditions, such as diabetes and cardiovascular disease.
The most common travel-related illness is diarrhea. The risk depends on the destination. At highest risk are persons who travel to Africa, Asia, and Latin America (20% to 50% risk). The risk is more moderate for those going to the Mediterranean or Caribbean regions (8% to 20% risk). Even those who visit the United States, Canada, northern Europe, and Australasia still face limited risk (up to 8%).1
Although diarrhea is commonly viewed as a minor problem, it can have a significant effect on business or pleasure trips. At least 20% of travelers who contract diarrhea spend part of their trip bedridden, and 40% change their itinerary because of diarrhea.2 Causes of traveler's diarrhea include enterotoxigenic Escherichia coli (which usually produces a self-limited illness that lasts only a few days), Campylobacter, Shigella, Salmonella, viruses, and parasites.
Prevention. Educate patients about basic preventive measures (Table 1). Simple hygiene and safety measures-such as frequent hand washing with soap and water, use of bottled water for drinking and brushing teeth, and eating well-cooked, hot foods-appear to greatly reduce the risk of diarrhea. Also, advise patients to avoid consumption of foods purchased from street vendors, uncooked foods (other than fruits or vegetables that they have peeled themselves), nonbottled beverages, and unpasteurized dairy products.
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| ||Table 1 — Prevention of traveler's diarrhea || |
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- Avoid uncooked food, other than fruits or vegetables that you have peeled yourself
- Peel any fresh fruits or vegetables
- Wipe off ice water used to chill beverage cans
- Avoid unbottled beverages and unpasteurized dairy products
- Eat well-cooked, hot foods
- Eat only food seen to have been prepared in hygienic conditions
- Avoid food purchased from street vendors
- Use bottled water for drinking, making ice, and brushing teeth
- Wash hands with soap and water frequently (especially before meals)
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Prophylaxis for traveler's diarrhea is no longer routinely recommended by most experts because of expense, possible adverse effects, and the risk of increased antibiotic resistance. Reserve prophylaxis for patients who may be forced to eat in areas where the safety of food and beverages is questionable, for those with reduced immunity, and for those in whom the potential consequences of illness could be profound. In such cases, preventive antibiotic therapy for adults consists of one of the following regimens, which should be followed daily while traveling, for a maximum of 3 weeks:
- Ciprofloxacin, 500 mg/d.
- Levofloxacin, 500 mg/d.
- Ofloxacin, 300 mg/d.
- Norfloxacin, 400 mg/d.
- If bottled water is not available, advise patients to boil water for at least
1 minute (3 minutes at altitudes above 2000 m) or to disinfect it with iodine
or chlorine. Cloudy water should be strained through a clean cloth and
twice the usual number of disinfectant tablets used.
- The most effective way to avoid prolonged jet lag is to adjust sleep and
activity cycles to match those of the local environment as soon as possible.
Other helpful measures include getting plenty of sleep before travel and
avoiding heavy drinking and overeating. Neither benzodiazepines nor melatonin
has been shown to be effective.
- To prevent venous stasis during air travel, encourage all patients to do
isometric calf exercises, maintain adequate hydration, and walk around the
cabin each hour. Persons who smoke, are obese, use oral contraceptives,
or have a history of deep venous thrombosis (DVT) are at heightened risk
- Patients with chronic medical conditions who might require acute care
during flights, cruises, or even bus tours should wear an identification
bracelet and bring emergency medications in their carry-on baggage.
- To reduce the risk of traffic accidents while traveling, encourage patients
to drive more slowly, avoid travel by motorcycle or overcrowded buses,
restrict travel to daylight hours, and avoid travel at times when other drivers
are likely to have been drinking.
Travel Medicine Kits:
What to Pack
Medicine or first aid kits are a necessity for travelers. Have
patients who take daily medications pack their drugs in
the original prescription bottles, along with a list of medical
conditions, allergies, medications, dosages, and physician
contact numbers. Patients with diabetes should include all
needed diabetic supplies, and those with heart disease, a copy of their latest
ECG. An extra pair of eyeglasses and a written copy of the prescription are
recommended. Other items to include in a travel medicine kit are:
- Prophylactic medications for motion sickness, altitude sickness, malaria,
traveler's diarrhea, etc.
- Oral contraceptives and/or condoms.
- The remedies normally used for pain, fever, nasal congestion, insect bites,
cuts, scrapes, and sunburn.
- First aid supplies, such as a thermometer, tweezers, gauze, and elastic
- Feminine hygiene supplies (which may be difficult to find while traveling).
- Insect repellent.
- Water purification supplies.
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